Lower-limb pain, disease, and injury burden as determinants of muscle strength deficit after hip fracture

Improvement of muscle quality assessed using the phase angle is influenced by recovery of knee extension strength in patients with hip fractures

BACKGROUND AND AIMS

Studies reported that knee extension strength on the operated side in patients with hip fractures was not recovered to the level on the non-operated side 6 months after surgery or later. In a cross-sectional study, we revealed that a reduction in isometric knee extension muscle strength on the operated side in patients with hip fractures approximately 6 months after surgery was associated with not only a reduction in skeletal muscle mass but also a reduction in muscle quality, characterized by a reduction in the phase angle (PhA). Furthermore, the mechanisms of knee extension strength improvement can be clarified in more detail using the minimal significant change as the index of recovery. However, no longitudinal studies have examined the factors for knee extension strength improvement based on the minimal significant change in patients with hip fractures 6 months after surgery. This study aimed to longitudinally examine the factors influencing the recovery of knee extension strength based on the minimal significant change in patients with hip fractures between 2 weeks and approximately 6 months after surgery.

METHODS

In this study, the outcomes used were basic and medical information, PhA, skeletal muscle index (SMI), pain, one-leg standing time, movement control during one-leg standing, and walking speed. For PhA, SMI, pain, one-leg standing time, movement control during one-leg standing, and walking speed, the amount of change was calculated by subtracting the data at 2 weeks from the data at 6 months. Group classification was determined by dividing the patients into two groups using a previous study as a reference: recovery group if the knee extension strength value approximately 6 months after surgery minus that 2 weeks after surgery was ≥3.3 kgf and non-recovery group if the value was <3.3 kgf. Logistic regression analysis was performed to explore the association between the recovery and non-recovery groups.

RESULTS

The recovery group contained 55 patients, while the non-recovery group comprised 35 patients. The only significant factor associated with knee extension muscle strength in the recovery group was the amount of change in PhA. The odds ratio for the amount of change in PhA was 2.26. The discrimination rate of the model was 62.5%.

CONCLUSIONS

Our results suggest that recovery of knee extension strength in patients with hip fractures after surgery was mainly because of improvements in muscle quality, not improvements in muscle mass or pain.

Factors Associated With Long-Term Quadriceps Muscle Function After Surgical Fixation of Lower Extremity Fractures

OBJECTIVE

The long-term performance of the quadriceps femoris muscle and physical function following surgical repair of a lower extremity fracture remains largely undefined. The purpose of this study was to investigate between-limb differences in quadriceps performance 12 months after surgical fixation of a lower extremity fracture. It was hypothesized that the injured limb would be significantly weaker, have a lower rate of torque development (RTD), and that there would be a reduced step-down performance compared to the uninjured limb 12 months after surgery. Additionally, this study sought to identify demographic, surgical, and psychological factors associated with poor quadriceps function 12 months after surgery.

METHODS

Quadriceps performance was measured bilaterally in 95 participants (49 female), aged 42 (SD = 14.5) years, 12 months after surgical fixation of a lower extremity fracture. Isometric quadriceps strength and RTD were quantified using isometric dynamometry, and a timed step-down test was used to evaluate quadriceps performance. Independent predictor variables from the time of surgery were extracted from participants' medical records. Kinesiophobia was screened at the time of testing. Wilcoxon signed-rank tests and linear regression analyses were used to assess between-limb differences in quadriceps performance and to determine factors associated with quadriceps performance 12 months after surgery.

RESULTS

Significant between-limb differences in each measure of quadriceps performance were identified (peak torque involved: 1.37 [0.71] Nm × kg-1; uninvolved: 1.87 [0.74] Nm × kg-1; RTD involved: 4.16 [2.75] Nm × kg-1 × s-1; uninvolved: 6.10 [3.02] Nm × kg-1 × × -1; and single-leg step-downs involved: 12.6 [5.0]; uninvolved: 21.7 [14.8]). Female biological sex, external fixation, and kinesiophobia at 12 months were associated with reduced after-surgery quadriceps performance outcomes.

CONCLUSION

Quadriceps performance is impaired 12 months after surgical repair of a lower extremity fracture, particularly in female participants, in cases requiring external fixation, and in those with higher kinesiophobia 12 months after surgery.

IMPACT

Because long-term quadriceps weakness negatively impacts functional mobility, targeted strengthening should be emphasized after surgical repair of lower extremity fracture.

Not only muscle mass but also muscle quality is associated with knee extension muscle strength in patients with hip fractures

Our results revealed that the decrease in isometric knee extension muscle strength on the operated and nonoperated sides in patients with hip fractures was associated with not only a decrease in skeletal muscle mass but also a decrease in muscle quality, characterized by a decreased PhA.

PURPOSE

This study aimed to assess the relationship between isometric knee extension muscle strength on the operated or nonoperated sides and PhA in patients with hip fractures at approximately 6 months postoperatively.

METHODS

This study was a cross-sectional study. Skeletal muscle index (SMI), PhA, knee extension muscle strength on the operated and nonoperated sides, and other physical function variables were assessed at approximately 6 months postoperatively. To identify predictors of knee extension muscle strength on the operated and nonoperated sides, hierarchical multiple regression analysis was performed.

RESULTS

A total of 90 patients with hip fractures were included (mean age, 80.1 ± 6.9 years). SMI (0.45) and PhA on the operated side (0.27) were the significant associated factors extracted for isometric knee extension muscle strength on the operated side (standardized partial regression coefficients), independent of age, sex, and body mass index (BMI). Movement control during one-leg standing on the nonoperated side (0.26), SMI (0.32), and PhA on the nonoperated side (0.40) were the significant associated factors extracted for isometric knee extension muscle strength on the nonoperated side, independent of age, sex and BMI.

CONCLUSIONS

Our results revealed that the decrease in isometric knee extension muscle strength on the operated and nonoperated sides in patients with hip fractures at approximately 6 months postoperatively was associated with not only a decrease in skeletal muscle mass but also a decrease in muscle quality, characterized by a decreased PhA.

The effect of gait training with low-intensity neuromuscular electrical stimulation of hip abductor muscles in two patients following surgery for hip fracture: Two case reports

Background: The rate of force development (RFD) is an indicator of muscle strength. A previous study reported that the RFD of hip abductor muscles was increased by neuromuscular electrical stimulation (NMES) to gluteus medius (GM) during gait in healthy adults. However, the effects for patients following femoral head replacement for hip fracture are unclear.Purpose: The aim of this case report was to investigate the effects of gait training with sub-motor threshold NMES on RFD of hip abductor muscles in two patients following femoral head replacement for hip fracture compared to gait training without NMES.Case description: Two elderly patients following femoral head replacement for hip fracture received both interventions of gait training with sub-motor threshold NMES to GM and without NMES. Intervention phases involved 14 sessions each, for 28 sessions total.Outcomes: The RFD of hip abductor muscles, maximum walking speed, six-minute walk distance (6MWD), Berg Balance Scale, one-leg standing time (OLST), functional independence measure, and Numeric Pain Rating Scale (NPRS) were used as outcome measures. In both patients, RFD, 6MWD, OLST, and NPRS were improved by gait training with NMES compared to without NMES.Conclusion: Our results suggest the potential of NMES as a treatment methodology for these two patients undergoing femoral head replacement for hip fracture.

Asymmetries Identified in Sit-to-Stand Task Explain Physical Function After Hip Fracture

BACKGROUND

Several known demographic and functional characteristics combine to predict physical function after hip fracture. Long-term weight-bearing asymmetries, evident during functional movements after hip fracture, contribute to limited mobility and large asymmetries in muscle function are linked to a high rate of injurious falls. Although postfracture mobility is commonly measured as whole body movement, a force-plate imbedded chair can identify individual limb contributions to an important task like moving from a sitting to standing position. The modified Physical Performance Test (mPPT) and stair climb test (SCT) are reliable, valid measures of function that predict independence after hip fracture. The purpose of this study was to determine to what extent asymmetry during a sit-to-stand task (STST) predicts function (mPPT, 12-step SCT), above and beyond other known predictors.

METHODS

Thirty-one independent community-dwelling older adults, recently discharged from usual care physical therapy (mean [standard deviation], 77.7 [10.5] years, 10 male), within 2 to 8 months postfracture, volunteered for this study. Participants performed an STST on a force-plate-imbedded chair designed to identify individual limb contributions during an STST. Asymmetry magnitude during the STST was determined for each individual. In addition, mPPT and SCT were assessed and regression analyses were performed to determine the contribution of asymmetry to the variance in these physical function scores beyond other factors predicting function.

RESULTS

Demographic factors (sex, time since fracture, repair type, and body mass index) were not significantly related to function in this sample. Age, gait speed, knee extension strength, balance confidence, and functional self-report were each significantly related to both mPPT (r = 0.43-0.86) and SCT (r = 0.40-0.83), and were retained in the regression model. Included variables accounted for 83.4% of the variance in mPPT score, and asymmetry during the STST did not significantly contribute to explaining variability in mPPT (P = .23). Variables in the regression model accounted for 78.0% of the variance in SCT score, and STST asymmetry explained 7.1% (P < .005) of the variance in SCT score.

DISCUSSION

In this small sample, asymmetry contributed significantly to explaining the variability in SCT performance, but not mPPT score. The SCT requires greater unilateral strength and control than the battery of items that comprise the mPPT. This contributes to the disproportionate number of falls occurring during stair ambulation (>10% of all fall-related deaths), relative to the minimal time typically involved in stair negotiation. Our results indicate potential benefit to identifying injured limb asymmetries as they predict function in challenging, high-risk functional tasks after hip fracture.

CONCLUSION

Although gait speed is the best explanator of physical function in older adults after hip fracture, lower extremity asymmetry during an STST provides a unique contribution to explaining high-level ambulatory performance after hip fracture. Efforts to reduce weight-bearing asymmetry during rehabilitation following hip fracture may improve function and recovery.

Effects of a Home-Based Physical Rehabilitation Program on Tibial Bone Structure, Density, and Strength After Hip Fracture: A Secondary Analysis of a Randomized Controlled Trial

Weight‐bearing physical activity may decrease or prevent bone deterioration after hip fracture. This study investigated the effects of a home‐based physical rehabilitation program on tibial bone traits in older hip fracture patients. A population‐based clinical sample of men and women operated for hip fracture (mean age 80 years, 78% women) was randomly assigned into an intervention (n = 40) and a standard care control group (n = 41) on average 10 weeks postfracture. The intervention group participated in a 12‐month home‐based rehabilitation intervention, including evaluation and modification of environmental hazards, guidance for safe walking, nonpharmacological pain management, motivational physical activity counseling, and a progressive, weight‐bearing home exercise program comprising strengthening exercises for the lower legs, balance training, functional exercises, and stretching. All participants received standard care. Distal tibia (5% proximal to the distal end plate) compressive bone strength index (BSI; g²/cm⁴), total volumetric BMD (vBMD_TOT; mg/cm³), and total area (CSA_TOT; mm²), as well as midtibia (55%) strength–strain index (SSI; mm³), cortical vBMD (vBMD_CO; mg/cm³), and ratio of cortical to total area (CSA_CO/CSA_TOT) were assessed in both legs by pQCT at baseline and at 3, 6, and 12 months. The intervention had no effect (group × time) on either the distal or midtibial bone traits. At the distal site, BSI of both legs, vBMD_TOT of the fractured side, and CSA_TOT of the nonfractured side decreased significantly over time in both groups 0.7% to 3.1% (12 months, p < 0.05). At the midshaft site, CSA_CO/CSA_TOT and SSI of both legs, and vBMD_CO of the fractured leg, decreased significantly over time in both groups 1.1% to 1.9% (12 months, p < 0.05). Trabecular and cortical bone traits of the tibia on the fractured and the nonfractured side deteriorated throughout follow‐up. The home‐based physical rehabilitation intervention aimed at promoting mobility recovery was unable to prevent bone deterioration in older people after hip fracture. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Structural and physical-functional deficits in lower limbs with fractures and treated surgically

Abstract Introduction: A fracture is a traumatic bone injury that can occur from a variety of causes. Although the repercussions of fractures on the musculoskeletal system are documented, studies with more comprehensive outcomes and later stages of injury are still scarce. Objective: To evaluate the structural and physical-functional adaptations in individuals who suffered unilateral lower limb fractures treated surgically. Methods: Thirty-two patients of both genders, aged between 18 and 59 years, with a diagnosis of unilateral fracture of the lower limb and hospital discharge of at least one year, participated in the study. The affected lower limb was compared to the healthy lower limb of all participants using the outcome measures: vastus lateral muscle thickness (ultrasonography), knee extension and flexion strength (isokinetic dynamometer), ankle dorsiflexion range of motion of the distance from the foot to the wall) and functional fitness of the lower limb (single and triple horizontal jump test). Results: Statistically significant differences were found between the limbs affected and not affected in the measurements of muscle thickness (p = 0.0001), knee extension force (p = 0.0094), dorsiflexion amplitude (p = 0.0004) and functional performance (p = 0.0094, single jump and = 0.0114, triple jump). In all significant outcomes, the values of the affected limb were smaller than that of the non-affected limb. The peak torque of the knee flexor muscles did not show a statistically significant difference between limbs (p = 0.0624). Conclusion: Individuals who have undergone a surgically treated unilateral fracture of the lower limb present important structural and physical-functional late changes in relation to the non-affected limb.

High-Intensity Multimodal Resistance Training Improves Muscle Function, Symmetry during a Sit-to-Stand Task, and Physical Function Following Hip Fracture

OBJECTIVES

Post rehabilitation, older adults with hip fracture display low vertical ground reaction force (vGRF) on the involved lower extremity during a sit-to-stand task and low physical function. The purpose of this study was to test whether muscle performance, involved side vGRF during a sit-to-stand task, and physical function improved following multimodal high-intensity resistance training, when initiated after usual care (2 to 6 months after hip fracture).

DESIGN

Case series study, 12 weeks extended high-intensity strength training intervention following hip fracture.

SETTING

University hospital outpatient facility.

PARTICIPANTS

Twenty-four community-dwelling older adults (mean age 78.4 years (SD 10.4), 16 female/8 male), 3.6 (SD 1.2) months post-hip fracture and discharged from physical therapy participated. Intervention/Measurement: All participants performed sit-to-stand tasks, muscle performance tests, and modified physical performance test (mPPT) before and after 12 weeks (3x/wk) of training. Variables were compared using paired t-tests.

RESULTS

The vGRF rate of force development (RFD) and magnitude of discrepancy between limb loading during rising phase of sit-to-stand task (AREA) variables improved post-training (RFD ratio = Pre: 0.78 - Post: 0.82, AREA ratio = Pre: 0.79 - Post: 0.86). Surgical leg extension power gains were large (~65%) while strength gains were moderate (~34%); yielding improved symmetry in both strength (Pre: 0.74 - Post: 0.88) and power (Pre: 0.75 - Post: 0.82). Physical function improved pre-training 25 (SD 5.2) to post training 30 (SD 4.3), (p < 0.001).

CONCLUSION

Unique to this study, participants recovering from hip fracture demonstrated improved symmetry in sit-to-stand vGRFs, muscle function, and physical function after training. However, a high percentage of patients continued to experience persistently low vGRF of the involved side compared to previous studies of healthy elderly controls. Developing alternative strategies to improve involved side vGRF may be warranted.

Comparison of Post-Operative Muscular Strength Between Gamma Nailing and Hemiarthroplasty System in Femoral Intertrochanteric Fractures

Background:

The current study focuses on the comparison of postoperative muscular strength around the hip joint of patients with femoral intertrochanteric fractures treated either by cephalo-medullary (CM) nailing or a new bipolar hip prosthesis (BHP), an especially attached device to secure displaced greater trochanteric fragment.

Methods:

Twenty patients treated with CM nailing were age- and sex- matched with a control group of 20 patients treated with BHP. Maximum isometric forces at the bilateral hip joint were measured during the follow up period. Means of 3 measurements were represented.

Results:

The mean and standard deviation values (kg) of muscle strength at the non-operative/ operative side in the CM nailing group were as follows: flexion strength 9.5±4.7/8.5±4.9 (P=0.06), extension strength 6.2±3.5/5.5±3.7 (P=0.08), abduction strength at 0 degrees 7.7±3.5/6.2±2.8 (p=0.002), abduction strength at 10 degrees 5.5±2.0/4.2±2.0 (p=0.001). In the BHP group, mean and standard deviation values of muscle strength at the non-operative/ operative side were as follows: flexion strength 6.5±2.8/6.0±3.4 (P=0.08), extension strength 4.4±0.9/4.4±0.6 (P=0.83), abduction strength at 0 degrees 5.1±1.9/5.0±1.6 (p=0.12), and that at 10 degrees 4.7±1.4/4.6±1.3 (p=0.10).

Conclusion:

Our results demonstrate that CM nailing may cause a 25-30% decrease in postoperative muscle strength around the hip joint, particularly during hip abduction. With the new BHP, greater trochanter reduction is achieved allowing early weight bearing and maintaining strength in abduction. Surgeons should consider postoperative muscular strength as one of the necessary factors for selection of the appropriate surgical procedure.

Level of Evidence:

Therapeutic Level III.

Knee extensor and flexor muscle power explains stair ascension time in patients with unilateral late-stage knee osteoarthritis: a cross-sectional study

OBJECTIVES

To determine the extent of asymmetrical deficits in knee extensor and flexor muscles, and to examine whether asymmetrical muscle deficits are associated with mobility limitations in persons with late-stage knee osteoarthritis (OA).

DESIGN

Cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

A clinical sample (N=56; age range, 50-75y) of eligible persons with late-stage knee OA awaiting knee replacement.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Knee extensor and flexor power and torque assessed isokinetically; thigh muscle cross-sectional area (CSA) assessed by computed tomography; mobility limitation assessed by walking speed and stair ascension time; and pain assessed with the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire.

RESULTS

The asymmetrical deficits in knee extensor and flexor power and torque were between 18% and 29% (P<.001). Regarding the thigh muscle CSA, the asymmetrical deficit was 4% (P<.001). Larger asymmetrical knee extensor power deficits and weaker knee extensor and flexor power on the contralateral side were associated with slower stair ascension times. Moreover, weaker knee extensor and flexor power on the ipsilateral side were associated with slower stair ascension times. Greater knee pain in the OA joint was independently associated with slower stair ascending time in both models.

CONCLUSIONS

The knee extensor and flexor muscle power of both the ipsilateral and contralateral sides and the pain in the OA knee were independently associated with stair ascension times. These results highlight the importance of assessing muscle power on both sides and knee pain in the prevention of mobility limitations in patients with knee OA.

Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial

OBJECTIVE

To investigate whether a home-based rehabilitation program for community-dwelling older people with recent hip fracture is more effective than standard care in improving mobility recovery and reducing disability.

DESIGN

Randomized, controlled, parallel-group trial.

SETTING

Rehabilitation in participants' homes; measurements in university-based laboratory and local hospital.

PARTICIPANTS

Clinical population of community-dwelling men and women (aged 60+) recovering from hip fracture. Participants were randomly assigned into control (n = 41) or intervention (n = 40) groups on average 42 ± 23 days after discharge home.

INTERVENTION

A yearlong multicomponent home-based rehabilitation aimed at promoting mobility recovery and physical functional capacity after hip fracture. The intervention included evaluation and modification of environmental hazards, guidance for safe walking, nonpharmacological pain management, a progressive home exercise program, physical activity counseling, and standard care.

MEASUREMENTS

Measurements were outlined according to the tiers of the disablement process, with the ability to negotiate stairs as the main outcome. Prefracture ability to negotiate stairs was enquired at the hospital on average 10 ± 5 days after fracture. Subsequently, current perceived ability to negotiate stairs was reported immediately before the intervention (on average 9 weeks after surgery) and 3, 6, and 12 months thereafter. Other measurements included leg extension power deficit (LEP), functional balance (Berg Balance Scale) and lower extremity performance (Short Physical Performance Battery). Effects of the intervention were analyzed with generalized estimation equations and longitudinal repeated measures mixture path models.

RESULTS

The intervention reduced perceived difficulties in negotiating stairs (interaction, group × time P = .001) from prefracture to 12 months compared with the control condition. The mixture path model revealed that less difficulty in negotiating stairs at 6 and 12 months correlated with better functional balance at 3 and 6 months in the intervention group but not controls (group difference P = .007 and P < .001, respectively).

CONCLUSION

The individualized home-based rehabilitation program improved mobility recovery after hip fracture over standard care. To be efficacious in reducing or reversing disability after hip fracture, rehabilitation needs to be individualized, include many components, be progressive, and span a sufficiently long period. Current Controlled Trials (ISRCTN53680197).

Balance confidence and functional balance are associated with physical disability after hip fracture

BACKGROUND

This cross-sectional study investigated the associations between balance confidence, functional balance, and physical disability among older people after hip fracture.

MATERIAL AND METHODS

The study utilizes baseline data of two randomized controlled trials (ISRCTN34271567 and ISRCTN53680197). The participants were 159 community-dwelling over 60-year-old people. Health, fracture status, the date and type of surgery, and contraindications for participation were assessed in a clinical examination. Balance confidence was assessed by the Activities-specific Balance Confidence Scale (ABC) and functional balance by the Berg Balance Scale. Physical disability was assessed by a questionnaire containing 14 questions on perceived difficulty in basic (ADL) and instrumental activities of daily living (IADL). Two sum scores were composed: ADL score (range 0-6) and IADL score (range 0-8). Isometric knee extension force was measured using a dynamometer. Pain and use of walking aids were assessed by a questionnaire. The negative binomial regression analysis was used to analyze the associations.

RESULTS

A higher ABC score was associated with a lower risk for ADL (IRR 0.99; 95% CI 0.98-0.99) and IADL disability (0.99; 0.98-0.99) in the fully adjusted models. Also a higher BBS score was associated with a lower risk for ADL (0.98; 0.96-0.99) and IADL disability (0.98; 0.97-0.99) in the fully adjusted models.

CONCLUSION

Decreased balance confidence and impaired functional balance are associated with physical disability in older people after hip fracture.

Hip fracture-related pain strongly influences functional performance of patients with an intertrochanteric fracture upon discharge from the hospital

OBJECTIVE

To examine whether functional performance upon hospital discharge is influenced by pain in the region of the hip fracture or related to the fracture type.

DESIGN

Prospective observational study.

SETTING

A 20-bed orthopedic hip fracture unit.

PATIENTS

Fifty-five cognitively intact patients (20 men and 35 women; ages 75.8 ± 10 years), 33 with a cervical hip fracture and 22 with an intertrochanteric hip fracture, all of whom were allowed to bear full weight after surgery.

METHODS

All patients were evaluated upon discharge from the hospital to their own homes at a mean of 10 ± 6 days after surgery.

MAIN OUTCOME MEASUREMENTS

The Timed Up & Go (TUG) test, supervised by a physical therapist, was used to evaluate functional performance, and a 5-point verbal ranking scale (0 = no pain to 4 = intolerable pain) was used to evaluate pain.

RESULTS

Patients took an average of 22.7 ± 11.7 seconds to perform the TUG. No significant differences were observed in baseline characteristics or pain medication given for patients with a cervical versus an intertrochanteric fracture (P ≥ .22), but patients with an intertrochanteric fracture presented more often with moderate to severe pain during testing (P < .001), with associated poorer performances on the TUG test (29.4 ± 12.8 seconds versus 18.3 ± 8.5 seconds). Univariate analysis showed that TUG scores were associated with age, prefracture function evaluated by the New Mobility Score, fracture type, day of TUG performance, and pain intensity. Multivariate linear regression analyses (fracture type not included) showed that only greater age (B = 0.34), low prefracture function (B = 7.9), and experiencing moderate to severe pain (B = 8.7) were independently associated with having a poorer TUG score.

CONCLUSIONS

Hip fracture-related pain primarily compromises the functional performance of patients with an intertrochanteric hip fracture upon discharge from hospital. Physical therapists should be involved in new and optimized fracture-type stratified pain management strategies.

Functional and radiographic outcomes of intertrochanteric hip fractures treated with calcar reduction, compression, and trochanteric entry nailing

OBJECTIVES

Shortening after intertrochanteric hip fractures with sliding constructs is an increasingly recognized problem by the orthopaedic community. It often results in a limb length discrepancy causing maladaptation of the abductor lever arm. Functional limitations can also result from altered hip biomechanics and negatively influence patient outcomes. We hypothesized that with trochanteric entry nailing, calcar reduction, and intraoperative compression, a near-normal restoration of gait parameters and satisfactory outcomes can be achieved.

DESIGN

Level 4, prospective descriptive study.

SETTINGS

Level 1 trauma care center.

PATIENTS/PARTICIPANTS

Fifty-eight patients with intertrochanteric hip fractures were managed operatively from 2007 to 2008. A strict exclusion criterion was used to analyze the data of interest for a final cohort of 30 patients.

INTERVENTION

Stable fixation was achieved with trochanteric entry nail after calcar reduction and intraoperative compression of the fracture site. Patients were grouped into stable (n = 17) and unstable (n = 13) fracture types based on the OTA classification. OUTCOME/MEASUREMENTS: Postoperative collapse was measured as telescoping of the lag screw from lateral cortex and blade tip migration within the femoral head. Alteration in femoral head offset and abductor lever arm was measured at the last follow-up visit. Gait parameters were recorded and compared with contralateral side at 6-week, 3-, 6-, and 12-month follow-up visits. Functional outcomes were assessed through 36-item short form health survey (version 2) and Harris Hip Scores at 1 year.

RESULTS

Fracture type (stable or unstable) significantly predicted telescoping (P = 0.007). Mean telescoping was 3.3 mm (SD = 2.41 mm) in the unstable group versus 1.2 mm (SD = 0.81 mm) in the stable group (P = 0.004). The stable group recovered 95% of the single limb stance versus 91% in the unstable group, at 1 year. (P = 0.02). Return of single limb stance improved from 76% to 95% between 6 weeks and 6 months. No improvement in gait was seen after 6 months (P > 0.05). The average scores on the physical and mental components of 36-item short form health survey and Harris Hip Scores were 44, 53, and 89, respectively. The radiographic union rate was 100%. There was 1 (3%) screw cutout that did not require a revision surgery in our series. There were no cases with implant failure, femur fracture, or any wound complications.

CONCLUSIONS

Satisfactory functional outcomes with near-normal gait restoration can be achieved in cases of intertrochanteric hip fractures with an emphasis on calcar reduction and compression after fixation with trochanteric entry nail.

LEVEL OF EVIDENCE

Therapeutic Level IV. See page 128 for a complete description of levels of evidence.

Promoting mobility after hip fracture (ProMo): study protocol and selected baseline results of a year-long randomized controlled trial among community-dwelling older people

Background

To cope at their homes, community-dwelling older people surviving a hip fracture need a sufficient amount of functional ability and mobility. There is a lack of evidence on the best practices supporting recovery after hip fracture. The purpose of this article is to describe the design, intervention and demographic baseline results of a study investigating the effects of a rehabilitation program aiming to restore mobility and functional capacity among community-dwelling participants after hip fracture.

Methods/Design

Population-based sample of over 60-year-old community-dwelling men and women operated for hip fracture (n = 81, mean age 79 years, 78% were women) participated in this study and were randomly allocated into control (Standard Care) and ProMo intervention groups on average 10 weeks post fracture and 6 weeks after discharged to home. Standard Care included written home exercise program with 5-7 exercises for lower limbs. Of all participants, 12 got a referral to physiotherapy. After discharged to home, only 50% adhered to Standard Care. None of the participants were followed-up for Standard Care or mobility recovery. ProMo-intervention included Standard Care and a year-long program including evaluation/modification of environmental hazards, guidance for safe walking, pain management, progressive home exercise program and physical activity counseling. Measurements included a comprehensive battery of laboratory tests and self-report on mobility limitation, disability, physical functional capacity and health as well as assessments for the key prerequisites for mobility, disability and functional capacity. All assessments were performed blinded at the research laboratory. No significant differences were observed between intervention and control groups in any of the demographic variables.

Discussion

Ten weeks post hip fracture only half of the participants were compliant to Standard Care. No follow-up for Standard Care or mobility recovery occurred. There is a need for rehabilitation and follow-up for mobility recovery after hip fracture. However, the effectiveness of the ProMo program can only be assessed at the end of the study.

Trial registration

Current Controlled Trials ISRCTN53680197